Home care billing in Florida

Managed long-term services and supports, statewide. CMS's 2024 state tables classify the Statewide Medicaid Managed Care MMA plus LTSS program as an MCO program with MLTSS, statewide, under 1115(a) and 1915(b)/1915(c) authority, and list its participating plans as Sunshine State Health Plan, Simply Healthcare Plans, Molina Healthcare of Florida, Humana Medical Plan, Florida Community Care, Aetna Better Health and UnitedHealthcare of Florida.¹ AHCA's October 2024 amendment request to the MMA demonstration, cited below, describes recipients receiving services under a single plan that provides MMA, Long-Term Care and specialty product benefits, with the former specialty plans incorporated into those plans as specialty products rather than standalone plans. Fee-for-service recipients are billed to the fiscal agent through the Florida Medicaid Web Portal, cited below.

Plan-managed. Each SMMC plan requires home health and personal care claims to come through its own EVV vendor: Humana Healthy Horizons in Florida routes them through HHAeXchange and denies claims from a provider that sends less than 25 percent of those claims through HHAeXchange, measured over a quarterly look-back.⁴ Sunshine Health also uses HHAeXchange and stopped accepting unconfirmed EVV claims on January 30, 2025; Aetna Better Health of Florida uses Tellus, as the pages cited below state. Sunshine Health's LTC section adds that its EVV system monitors visits in real time, alerts the provider when a visit is not initiated as scheduled or authorized, expects the visit to be fulfilled within 48 hours of the start date, and requires missed visits to be reported in the EVV system with services resuming within three hours of notification. AHCA's own EVV page refused automated access at review, so the fee-for-service arrangement is not described here.

Services under EVV⁵

• Medicaid home health services, for dates of service on or after June 21, 2021, submitted through the plan's EVV vendor
• Medicaid personal care services, for dates of service on or after June 21, 2021, submitted through the plan's EVV vendor

Through the plan's care manager. Sunshine Health's manual makes LTC providers responsible for collaborating with the plan to identify and authorize appropriate services, has the Care Manager coordinate with service providers on discharge planning and transition case management, and states that failure to obtain authorization for services may result in payment denials. On receipt of an authorization, LTC providers must confirm staff availability promptly and no later than one business day.³ Authorization requests for home health and DME services for LTC members, home infusion services, wound vacs and PDN follow a separate route from the plan's Coastal Care process. Each plan sets its own authorization channels, so the biller keeps a per-plan sheet of where requests go and what the plan's manual requires on them.

To the member's SMMC plan. Sunshine Health's manual commits the plan to pay or deny a clean claim within 20 calendar days for EDI submissions and 40 calendar days for paper, with a pended claim closed within 35 calendar days of being pended, and home health and personal care claims reach the plan through its EVV vendor rather than directly.³ Aetna Better Health of Florida, cited below, denies home health and personal care claims submitted outside Tellus and processes a claim outside the vendor only case by case when a documented vendor system issue blocked you. Fee-for-service claims go to the fiscal agent through the Florida Medicaid Web Portal within the 12-month federal outside limit in 42 CFR 447.45; plan limits are shorter and differ, and Community Care Plan's manual, for example, denies claims received more than 180 days after the date of service.

Palmetto GBA, LLC, the A/B MAC for Jurisdiction M, processes Medicare home health and hospice claims for Florida, together with Alabama, Arkansas, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee and Texas.⁷ AHCA's home health coverage policy and Florida's home health agency licensure pages refused automated access at review, so the Medicaid home health benefit and the state license requirements are not described here. The plan-side rules are in the manuals cited above: Sunshine Health lists intermittent and skilled nursing and hospice among LTC covered services and routes home health and PDN authorizations for LTC members separately.